Thanks to a tweet by @PushforMidwives I discovered this amazing story from the Tennessean.

Please read the whole piece, but for my purposes I will use the time-honored tradition of “fisking”, to take on each deeply-conflicted section of this article one at a time. Article text is in italics; some text bolded for emphasis.

Lower TennCare rates for C-sections upset obstetricians

Right off the bat, we know who is the subject of this story, and how it is being framed; as a battle between OBs and the force or forces driving lower c-section rates.

What’s even more interesting is that there’s a double meaning in the word “rates”—it might mean, at the beginning of the article, “number of c-sections” but also “what OBs will get paid for c-sections.”

But I will give the writer Tom Wilemon some slack here, because reporters seldom get to write their own headlines.

That’s the assessment of obstetrics professors with Vanderbilt University and Meharry Medical College, who say the biggest losers could be hospitals, especially smaller ones with limited sources of revenue.

Now this is attention-getting. First of all, the assertion of the utter inability, in the face of c-section reform, of hospitals and doctors to handle any births whatsoever.

Remember: all c-sections are not being banned, but “unneeded” ones reduced. Yet apparently this change, which seems both medically sound and fiscally responsible, will shut down obstetrics departments across the state.

The buried assertion (and to me, the buried story) is this implication: it was only the fees from unneeded c-sections, those performed on poorer TennCare patients no less, that were keeping many obstetrics programs afloat in the first place.

In other words, we are being told that in order to preserve hospital access to all birthing women in Tennessee, some percentage of the birthing population are currently acting as sacrificial lambs, and are having unneeded surgeries in order to keep the machinery running. And that this is necessary and unavoidable; in fact, no other type of action for changing this situation is even suggested.

We are also told that the biggest losers are the hospitals, not the women being threatened with having no place to birth, and certainly not those having admitted unnecesareans.

Under Gov. Bill Haslam’s proposed spending plan for next year, hospitals and obstetricians would get only half of what they now receive for C-sections. The change is projected to save $14.9 million, accounting for more than one-third of the overall cuts to TennCare.

“In my opinion, the state is just trying to save money on the backs of hospitals and doctors,” said Dr. Frank H. Boehm, professor of obstetrics and gynecology at Vanderbilt. “I don’t think there is any big medical reason to do this.”

I’m just going to bold this oddly casual statement, considering that Dr. Boehm is discussing surgery performed on thousands of women in his state. He either believes that all c-sections are necessary and the whole “reducing unneeded c-sections” thing is a crock and a cover for slashing payments, or he also wants to preserve the unnecessareans-as-financial-engine model. It is hard not to suspect he falls into the second group, because he expresses no concern whatever about womens’ health risks going up if c-section rates go down—once again, it’s about OBs and hospitals, not their patients.

Currently, the average reimbursement rate for a C-section is $6,623. That figure would fall to the same rate as a vaginal delivery, which would be about $3,300 under the proposal — a 5 percent increase from the current amount.

Here “rates” refers to OB/hospital reimbursement.

Dr. Wendy Long, the chief medical officer for TennCare, gave both financial and health policy reasons for the change during the governor’s budget hearings.

“C-sections are considerably more expensive than non-C-sections,” Long said. “In many cases, they are absolutely necessary, but in other cases the C-sections are more elective in nature, so we hope to see a reduction in elective C-sections.”

She pointed out that TennCare C-section rates, which stood at about 20 percent in the late 1990s, now account for about 30 percent of deliveries.

And we are back to “rates” as “number of c-sections.” If we had not already been told that elective or unneeded c-sections were a financial necessity earlier on, it would be difficult to see how reducing this expensive form of surgery would be a bad thing for obstetrics departments and hospital access in general, which may be why Dr. Long doesn’t find it alarming; perhaps she did not get that memo.

Meanwhile, Dr. Janice E. Whitty has gotten a different memo, this one familiar to most Unnecesarean readers:

But that increase does not mean that the surgical deliveries were elective, said Dr. Janice E. Whitty, chief of obstetrics at Meharry.

“It is very true that the rate of cesarean deliveries is increasing, but it is not increasing just because of convenience. It is increasing because of the repeat cesarean deliveries that occur,” Whitty said. “Many doctors now don’t want to face the liability of doing a vaginal birth after a cesarean section.”

I continue to be amazed by doctors and hospitals who think it is ethical to perform unnecessary surgeries in order to protect themselves from lawsuits, and who will say so to anyone who asks. And who maintain that “done to prevent lawsuits” does not fall under “elective.” It would be hard to think of a more elective reason to expose a patient to surgical risks.

But wait…here’s a bit about medical necessity:

A vaginal delivery after a mother has previously given birth through a C-section carries the risk of a uterine rupture, which can result in death of the mother or the child.

“If a woman needs a cesarean section, the obstetrician has to perform a cesarean section,” Whitty said.

And here we have the standard uterine rupture talking point familiar to Unnecessarean readers, as usual not backed up with data, but it does bear the distinction of being a medical, and not a litigious or financial, reason to c-section a woman. Points for that.

The procedure involves extra costs, including anesthesia and surgical staff.

“You may find that some hospitals will give up the practice of obstetrics if they are not reimbursed at a rate that will cover their expense for a cesarean delivery,” Whitty said. “There are quite a number of expenses involved.”

But if shutting down obstetrics departments means there are no obstetricians close enough, will women giving birth face increased risks of death or injury? Another unasked question.

I will give them this; refusing to do *any* births if you can’t c-section is more consistent than refusing VBACs only because they might need c-sections, even though you are prepared to c-section non-VBAC births if necessary. Points for that too, I suppose, although “there are quite a number of expenses involved,” is so vague that it does not increase one’s faith that hospitals can actually justify what they were charging in the first place.

But let’s get on to the important stuff: money and politics.

$14.9M is biggest chunk

The other big cuts to the TennCare program included $12.7 million by reducing non-hospital reimbursement rates to doctors by 1.5 percent and $8.4 million derived by reducing payments to emergency room physicians when they perform triage procedures.

But those cuts do not approach the hits that obstetricians will take. The $14.9 million derived by halving what they receive for C-sections accounted for the biggest chunk of the $39.9 million in total cuts.

“It’s disappointing that obstetricians are being singled out here,” Boehm said. “Keep in mind we’re not getting a huge amount of money for this. It’s not like we are getting a huge fee for cesarean sections to begin with. Keep in mind this is the TennCare population. This is about half of patients in the state. I think about half of our OB population are on TennCare.”

It would be useful to know a few things here; how much revenue birth brings into a hospital, what the other doctors and ER physicians think about their cuts, and the politics behind cutting healthcare for so many Tennessee citizens. Again, though, I give the reporter some slack; this whole piece has a slashy, edited feel, and his original article might have had more meat to it. Reporters get paid even less than TennCare OBs, after all.

The legislature will have final say on the proposed cuts. TennCare is not the only state agency that would get less funding. The average reduction Haslam seeks throughout state government is 2.5 percent.

But the change in C-section reimbursements surprised obstetricians. Said Whitty: “I was stunned that such a proposal would be made.”

Throughout this article women remain completely invisible, except as dollars to be fought over/fees to be charged. Their health, and how it relates to more or fewer c-sections or to hospital access, remains almost entirely outside the discussion, except in ways that are disturbingly unrelated to medical necessity.

However, if you follow the article link, there is one place the women do show up in relation to this article; in the comments section, where they are accused of being illegal immigrants and having too many children at public expense.

Reader Comments (116)

Amy,

How about you break down the logic that drove you to write the following paragraph in your 1994 book?

Nonetheless, it is possible to have too much of a good thing. The odds are as high as 1 in 5 that Caesarean section will be recommended to you. How will you know if it is the right procedure for your situation? How can you avoid having an unnecessary Caesarean section? The first step toward answering both questions is to understand exactly what a Caesarean section is—and when it is recommended.

And again, give me something fresh, please. The whole “But we can’t know in advance who NEEDS a cesarean so therefore we shouldn’t think about lowering the rate” shtick has been done. Again and again. And again. It’s great that you want to engage people and challenge them to examine why they want to see fewer cesareans, but it’s like Groundhog’s Day.

As a family medicine doc delivering a mostly NC medicaid population, I do sympathize with both women pushed into C-sections and the OBs in this story. I don't do c-sections and must depend on my OB collegues when push comes to cut. The article is written badly and really should be asking, "Is this how we reduce C-section rates?". In NC we're starting a pregnancy home concept with Medicaid patients, (encouraging follow-up, better documentation, no pre-approval for U/S!!) that offers increased reimbursement for vaginal deliveries. C-section rate doesn't change, but the vaginal delivery rate increases. The state believes it will save money overall with better coordinated care and increased vaginal deliveries. We'll see which method helps lower the c-section rate, but I'm betting on ours.

First of all I think that overall and on the average, financial incentives do drive people's actions in almost every field of life. From the above MD's figures, he doesn't have a very large financial incentive to perform C sections on Tenncare patients. However he does leave out of his assessment the amount of work invested in each delivery, and how many of each kind of delivery he can do within a certain time period. It does seem though, as if the hospitals have more incentive to have C sections performed than do the doctors. If this is true, they will encourage C sections, not openly, but by their hospital policies about every aspect of labor management which affects the C section rate. I would like to see the reimbursement for both kinds of deliveries made equal, but perhaps it needs to be more than the previous rate for vaginal deliveries, so as to come closer to what hospitals say is their cost of operating an OB unit. However the governor of the state has a financial interest not in lowering C sections, but in reducing the cost of Tenncare (medicaid) to the state. I hope when this proposal is amended, it is amended in the direction of increasing the reimbursement for a delivery of any kind, rather than in the direction of reinstating the C section premium.

The Law of Gravity is 300+ years old. Does that mean we should discard it because it isn't "fresh"?

If you want to debate the point then all you have to do is show us a method to determine in advance which C-sections are unnecessary. And you have to show that your method has very high sensitivity and specificity. Can you do that?

I also want to comment on Dr. Tuteur''s comments. She is saying that it is acceptable to section a third of women because doing so saves some babies. Not the babies of all 33 of 100 women...but of how many? I think this is a value judgment which needs to be more in the open and not assumed. How many surgeries are justified to save one baby? I certainly don't think it is an infinite number-does anyone here want to say that? Suppose of the 33 women who are sectioned, one baby would have died without the section? Or is it that of 1000 women with 330 C sections, one baby would have died? Or of 10,000 women having 3300 sections, if one baby was saved, does that justify 3300 sections? I don't know what these numbers really are. But iit seems as if right now, the acceptable number of infant deaths is considered to be zero NO MATTER HOW MANY WOMEN UNDERGO MAJOR SURGERY TO ACHIEVE THAT. Suppose it were 330 sections to save 1 baby. Is it an acceptable cost to our society for 330 women to undergo major surgery which does decrease their ability to bear children in the future when you consider how difficult it is to get a VBAC in the hospital and all the problems associated with multiple repeat C sections. I know a woman who went into her marriage intending not to limit her family at all unless a serious reason to do so emerged, and in that case only to do so by natural family planning. Since she married quite young, her expectation was of having perhaps eight to ten children, the norm in the families on both sides. Well, now, she has had three C sections in under four years, and is still in the years of highest fertility. She is pretty much stuck having C sections. I don't think she was best served by having the "zero allowable infant death" criterion applied during her first labor. I certainly felt that way myself when I was sectioned with my first baby, klnowing I would not contracept, and also not knowing if I would ever have medical insurance to pay for repeated C sections. ( I paid out of pocket for my first three births, which was a lot of money for me but nothing like what it costs now.) If anyone had asked me, I would have wanted to know what the chances were of my baby having an infection because my water had been leaking for three days, and if they told me that the chance was (making these numbers up) 5%, with 25% of those infected dying, I would have said that in my particular situation I was willing to take that risk rather than the risk of being put eventually in the situation of having pregnancies which were medically dangerous and for which I could not pay. IIt turned out that my doctor's statement that the C section meant all my babies would have to be born that way was not true, and I had 8 vaginal deliveries after that one. But I bring these cases up just as an example to show that there can be reasons to take SOME risk of having a baby die rather than to perform a C section.

Even if most women are having many fewer babies than I and some of my friends have, does their bodily integrity and their future ability to birth normally mean absolutely NOTHING? I ask again, how many unnecessary C sections can be justified in order to save one baby? Can anyone figure out approximately how many there might actually be? Or how intervention criteria could be changed if we could establish a threshold?

Amy, are you suggesting that since some births will require surgical intervention, and all of those cannot be determined in advance, we should consider all c-sections "necessary" even when there are easily identifiable factors in play that are proven to increase c-section rates without improving outcomes?

"Can't you see that the only reason that anyone wants to lower the cesarean rate is because they are biological essentialists who want to force women to have babies come out of the their vaginas against their will?"